Whats the difference between depression and grief?
- Grief reaction:
- --Normal reaction to loss
- --Related to significant loss
- --Stop normal activities
- --Focus on present feelings & needs
- --Adjustment is the outcome
- Grief reaction can become abnormal:
- --Depression can be a distorted grief reaction.
- --Grief can become pathological grief reaction
Affective SnSs of Depression
- Anger & anxiety
- Apathy & bitterness
- Dejection & guilt
- Denying feelings
- Sad and despondent
- Helpless & hopeless
- Low self-esteem
Cognitive SnSs of depression
- Confusion, uncertainty
- Unable to concentrate
- Indecisiveness/loss of motivation
- Loss of interest
- Pessimism & self- depreciation
- Self-destructive thoughts
- Suicidal ideation. At risk when pt has lost hope of recovery.
Behavioral SnSs of depression
- Decreased activity. Requires prompting to accomplish ADLs.
- Lacks spontaneity
- Suicidal gestures & acts
- Poor hygiene & lack of ADLs
- Social isolation/withdrawn
- Alcoholism & drug use-
Who is at risk for suicide?
- Decreased 5HT (serotonin) and/or NE (norepinephrine)
- People with chronic, debilitating illness
- History of depression
- Concurrent psychiatric illnesses:
- - Substance Abuse/Dependence
- - Panic disorder
- - Bipolar disorder
- - Obsessive-compulsive disorder
- Prior suicide attempts
- Negative Evaluation of Self
- - Pessimism & negative evaluation of self/others/world
- - Cognitive distortions and faulty thinking
- Lack of social support
- Stressful life events
- Personal history of sexual abuse
- Sexual orientation issues
- People with unresolved grief
- Humiliating life event
When does depression become major depression?
When it lasts more than 2 weeks.
What is anhedonia?
When a depressed pt can no longer experience pleasure in an activity they used to find pleasurable.
What is dysthymia?
- When depression lasts 2 or more years. May occur in a pattern with more days depressed than not.
- Symptoms are generally not as severe as with major depression.
What are some theories of depression?
- Psychoanalytic: associated with loss & is anger turned inward against the self
- Beck-Cognitive Therapy: Negative and faulty thinking
- Neurochemical imbalance: Low levels of 5HT (serotonin)/ Low levels of norepinephrine
What are some nursing interventions for a pt with depression?
- Administer Medications (See Medication Sheet):
- --MAO inhibitors
- --Others antidepressants
- Monitor medication side effects, especially loss of appetite. Must be getting food/fluids.
- Assess suicidal ideation
- 1:1 for short periods
- Cognitive restructuring for thinking
- Deal with anger and externalize as needed
- Avoid acting cheerful
- Mute-make observations of patient’s response to environment & document
- Use simple, concrete words and sentences
- Work on problems to gain acceptance of self
- Cognitive restructuring for distortions in thinking
- What to do for paradoxical calm? Paradoxical calm is when pt with suicidal ideation suddenly gets better because they've come up with a plan, and having a plan makes them feel good. Do not d/c and watch closely for suicide attempts.
How do SSRIs work?
- Seratonine Synapse Reuptake Inhibitor.
- Blocks seratonine's ability to taken up when it does not enter a receptor.
How do you assess for suicidal ideation?
- “Are you thinking about killing yourself?”
- “Have you thought about hurting yourself?”
- “When people are as upset as you seem to be, they sometimes wish they were dead. I’m wondering if you are thinking about harming yourself?”
- Presence of a plan & lethality
- “Are you thinking about hurting yourself right now? If that changes, will you promise to talk with someone before you make an attempt?”
- Nurse’s role in documentation
- Assess overt/covert cues
- --Covert: Hoarding clues, giving things away, saying good-bye, getting affairs in order.
What are some nursing interventions for pt with suicidal ideation?
- Ask directly about suicidality
- Document patient safety and action taken
- Unit & patient searches to provide safe environment
- Remove harmful objects
- Suicide precautions
- 15 min, 30 min. and hourly checks
- 72 hour holds
- Monitor patient closely
- Sitter for extreme suicidality
- Line of site
- Watch for elopement
What to do for Treatment Resistant Depression Major.
- Electroconvulsive Therapy: Thought to increase dopamine, serotonin, and norepinephrine by various mechanisms
- Vagus Nerve Stimulator: Placement of internal device used for epilepsy
- Functional EEG: matching of medication
What is mania?
- Elevated mood including 3 of the following: Inflated self-esteem or grandioseDecreased sleep
- Increase talkativeness
- Pressured speech: speaking on top of yourself. Words cannot flow fast enough.
- Flight of ideas
- Thoughts racing
- Increase in goal-directed activity (socially, at work or sexually)
- Excessive involvement in pleasurable activity
- Sexual indiscretions, buying sprees, foolish business investments
What is hypomania?
- About the same as mania, but less and no psychotic symptoms.
- Less severe than for mania
- Less impairment in social/occupational functioning
- Does not usually need hospitalization
Bipolar I vs II
- I: Is predominately manic with a few depressed episodes
- II: Is predominately depressed with a few manic or hypomanic episodes. Harder to diagnose
Both are genetic and are characterized by a chemical imbalance in the brain.
What is bipolar depression?
- More amendable for treatment
- Symptoms similar to Major Depression
- Monitor for suicidal ideation
- Medication used to treat are different
- Use of Mood Stabilizers
- Antidepressants used with caution since they can precipitate manic episodes
What are nursing interventions for pt with bipolar disorder?
- Administer medications & monitor side effects (1st line intervention is Rx)
- --Lithium (Therapeutic vs toxic levels)
- Administer low doses of antipsychotics, to decrease impulsive behaviors.
- PRN Benzodiazepines: helps to focus and relax.
- Give finger foods.
- Give fluids to drink
- --Want high calories because they will be burning them at a tremendous rate.
- Do not laugh at jokes
- Use firm, calm approach
- Use short, simple words & explanations
- Be consistent with approach
- Set limits on behavior
- Provide a structured environment
- Avoid power struggles
- Send to room to calm down if escalates
- Use time outs
- Redirect energy constructively
- Protect from self harm
- Remain calm
How do you monitor for Lithium toxicity?
- Vary narrow therapeutic level.
- (Level indicates multiple above therapeutic level.)
- 2.0 level:
- Coarse hand tremor
- Hyperactive deep tendon reflexes
- Over 2.5:
- decrease urine output,
- decreased BP,
- irregular pulse,
- ECG changes,
- impaired consciousness,
- coma and death